Pancreas
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Volume 43, Number 4, May 2014
8. Makhija R, Kingsnorth AN. Cytokine storm in acute pancreatitis. J Hepatobiliary Pancreat Surg. 2002;9:401Y410. 9. Hirota M, Nozawa F, Okabe A, et al. Relationship between plasma cytokine concentration and multiple organ failure in patients with acute pancreatitis. Pancreas. 2000;21:141Y146. 10. Kim YC, Song SB, Lee MH, et al. Simvastatin induces caspase-independent apoptosis in LPS-activated RAW264.7 macrophage cells. Biochem Biophys Res Comm. 2006;339:1007Y1014.
Synchronous Diagnosis of Primary Pancreatic Adenocarcinoma and Renal Cell Carcinoma A Case Report and Review of the Literature To the Editor:
W
hen a pancreatic mass is encountered, histologic diagnosis is crucial to guide therapy. Extrapancreatic tumors may metastasize to the pancreas and simulate a primary pancreatic cancer including renal cell carcinoma, lung, breast, melanoma, and gastrointestinal tract tumors of the stomach, small bowel, colon, and rectum.1Y5 In addition to primary pancreatic cancer and metastases, we must consider the unusual presence of 2 synchronous tumors. The aim of this case report and review of the literature is to present a patient with synchronous diagnosis of renal cell carcinoma and primary pancreatic adenocarcinoma to highlight the need to consider dual primary cancers when evaluating new pancreatic masses.
Letters to the Editor
CASE REPORT A 65-year-old white man with a history of well-controlled hyperlipidemia presented with acute onset of painless jaundice and dark urine over a 5-day period, with associated exertional fatigue. The patient had no other symptoms including abdominal or back pain or discomfort, nausea, or weight loss. Physical examination revealed stable vital signs and was only significant for jaundice. Laboratory studies revealed a normal complete blood cell count and elevated liver function tests, with total bilirubin level, 6.3 mg/dL; direct bilirubin level, 5.19 mg/dL; aspartate aminotransferase, 149 units/L; alanine aminotransferase, 308 units/L; alkaline phosphatase, 964 units/L; amylase, 594 units/L; and lipase, 10,984 units/L. A computed tomography scan of the abdomen and pelvis with intravenous contrast showed a mass in the lower pole of the left kidney measuring 5.6 6.5 5.3 cm (Fig. 1), with radiographic features consistent with renal cell carcinoma, common bile duct (CBD) dilatation to 1.7 cm, and mild heterogeneity and prominence of the pancreatic head with no clearly defined mass and no vascular invasion. A subsequent magnetic resonance imaging of the abdomen with and without contrast and magnetic resonance cholangiopancreatography revealed an indeterminate area in the pancreatic head measuring 2.0 1.8 cm, CBD dilation to 1.4 cm with abrupt narrowing in the pancreatic head, and the previously identified centrally necrotic left lower pole renal mass. Endoscopic ultrasound (EUS) was then performed for further evaluation of the pancreatic mass. The EUS revealed a hypoechoic and anechoic mass in the pancreatic head measuring 3.2 2.7 cm with poorly defined borders, with CBD dilatation to 1.5 cm without vascular invasion (Fig. 1). Fine-needle aspiration (FNA) of the pancreatic mass
was performed via duodenal approach, with pathology revealing pancreatic adenocarcinoma. Preoperative CA 19-9 level was 342.9 units/mL. The patient underwent combined Whipple procedure and partial left nephrectomy. Surgical pathology confirmed primary pancreatic adenocarcinoma and primary renal cell carcinoma.
DISCUSSION Renal cell carcinoma metastasizing to the pancreas is well described and can result in isolated mass lesions in the head, body, or tail of the pancreas.2,6 These lesions can simulate primary pancreatic tumors, but their management may not be the same. Diagnosis of renal cell carcinoma is primarily made via classic imaging characteristics with management of primary lesions being almost exclusively surgical for pathologic confirmation and resection.7 The EUS with FNA of pancreatic mass lesions has been increasingly used for preoperative diagnosis.8 In this case, the use of EUS with FNA yielded histologic examination result that confirmed the presence of a primary pancreatic adenocarcinoma and not a metastatic lesion from the presumed renal mass. Other tumors that may metastasize to the pancreas include lung, breast, melanoma, and gastrointestinal tract (stomach, small bowel, colon, and rectum).1,3Y5 To date, there are 4 reports comprising 6 patients with synchronous diagnosis of histologically proven pancreatic adenocarcinoma and renal cell carcinoma, published in the English language.9Y12 Although 2 synchronous primary tumors are rare to find, it is important to approach solid masses of the pancreas as if they could be a primary pancreatic tumor in combination with a second primary tumor to enable appropriate diagnostic evaluation and proper therapeutic interventions.
FIGURE 1. A, Endoscopic ultrasound image of a hypoechoic mass in the head of the pancreas measuring 3.2 2.7 cm with anechoic areas and poorly defined endosonographic borders. B, Coronal image from the abdominal computed tomography scan with intravenous contrast of an enhancing mass in the lower pole of the left kidney measuring 5.6 6.5 5.3 cm. * 2014 Lippincott Williams & Wilkins
www.pancreasjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
663
Pancreas
Letters to the Editor
ACKNOWLEDGMENTS There were no sources of funding or financial disclosures for this manuscript. Study funding was provided exclusively by institutional funds. No outside funding sources were obtained. The authors declare no conflict of interest. Jodie A. Barkin, MD Atoosa Rabiee, MD Enrico O. Souto, MD Division of Gastroenterology Department of Medicine University of Miami Leonard M. Miller School of Medicine Miami, FL [email protected]
2. Wente MN, Kleeff J, Esposito I, et al. Renal cancer cell metastasis into the pancreas: a single-center experience and overview of the literature. Pancreas. 2005;30:218Y222.
&
Volume 43, Number 4, May 2014
guidelines/renal-mass.cfm. Accessed November 7, 2013.
3. Olson MT, Wakely PE Jr, Ali SZ. Metastases to the pancreas diagnosed by fine-needle aspiration. Acta Cytol. 2013;57:473Y480.
8. Puli SR, Bechtold ML, Buxbaum JL, et al. How good is endoscopic ultrasound-guided fine-needle aspiration in diagnosing the correct etiology for a solid pancreatic mass?: a meta-analysis and systematic review. Pancreas. 2013;42:20Y26.
4. Adsay NV, Andea A, Basturk O, et al. Secondary tumors of the pancreas: an analysis of a surgical and autopsy database and review of the literature. Virchows Arch. 2004;444:527Y535.
9. Bharthuar A, Pearce L, Litwin A, et al. Metastatic pancreatic adenocarcinoma and renal cell carcinoma treated with gemcitabine and sunitinib malate. A case report. JOP. 2009;10:523Y527.
5. Roland CF, van Heerden JA. Nonpancreatic tumors with metastasis to the pancreas. Surg Gynecol Obstet. 1989;168:345Y347.
10. Kawabe K, Ito T, Okano S. Simultaneous double cancers in the pancreas. Clin Gastroenterol Hepatol. 2011;9:A40.
REFERENCES
6. Kassabian A, Stein J, Jabbour N, et al. Renal cell carcinoma metastatic to the pancreas: a single-institution series and review of the literature. Urology. 2000;56:211Y215.
11. Alexakis N, Bosonnet L, Connor S, et al. Double resection for patients with pancreatic cancer and a second primary renal cell cancer. Dig Surg. 2003;20:428Y432.
1. Robbins EG 2nd, Franceschi D, Barkin JS. Solitary metastatic tumors to the pancreas: a case report and review of the literature. Am J Gastroenterol. 1996;91:2414Y2417.
7. American Urological Association. Guideline for Management of the Clinical Stage 1 Renal Mass 2009 [cited 2013 November 7, 2013]. Available at: http://www.auanet.org/education/
12. Mu¨ller SA, Pahernik S, Hinz U, et al. Renal tumors and second primary pancreatic tumors: a relationship with clinical impact? Patient Saf Surg. 2012;6:18.
664
www.pancreasjournal.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
&
Volume 43, Number 4, May 2014
8. Makhija R, Kingsnorth AN. Cytokine storm in acute pancreatitis. J Hepatobiliary Pancreat Surg. 2002;9:401Y410. 9. Hirota M, Nozawa F, Okabe A, et al. Relationship between plasma cytokine concentration and multiple organ failure in patients with acute pancreatitis. Pancreas. 2000;21:141Y146. 10. Kim YC, Song SB, Lee MH, et al. Simvastatin induces caspase-independent apoptosis in LPS-activated RAW264.7 macrophage cells. Biochem Biophys Res Comm. 2006;339:1007Y1014.
Synchronous Diagnosis of Primary Pancreatic Adenocarcinoma and Renal Cell Carcinoma A Case Report and Review of the Literature To the Editor:
W
hen a pancreatic mass is encountered, histologic diagnosis is crucial to guide therapy. Extrapancreatic tumors may metastasize to the pancreas and simulate a primary pancreatic cancer including renal cell carcinoma, lung, breast, melanoma, and gastrointestinal tract tumors of the stomach, small bowel, colon, and rectum.1Y5 In addition to primary pancreatic cancer and metastases, we must consider the unusual presence of 2 synchronous tumors. The aim of this case report and review of the literature is to present a patient with synchronous diagnosis of renal cell carcinoma and primary pancreatic adenocarcinoma to highlight the need to consider dual primary cancers when evaluating new pancreatic masses.
Letters to the Editor
CASE REPORT A 65-year-old white man with a history of well-controlled hyperlipidemia presented with acute onset of painless jaundice and dark urine over a 5-day period, with associated exertional fatigue. The patient had no other symptoms including abdominal or back pain or discomfort, nausea, or weight loss. Physical examination revealed stable vital signs and was only significant for jaundice. Laboratory studies revealed a normal complete blood cell count and elevated liver function tests, with total bilirubin level, 6.3 mg/dL; direct bilirubin level, 5.19 mg/dL; aspartate aminotransferase, 149 units/L; alanine aminotransferase, 308 units/L; alkaline phosphatase, 964 units/L; amylase, 594 units/L; and lipase, 10,984 units/L. A computed tomography scan of the abdomen and pelvis with intravenous contrast showed a mass in the lower pole of the left kidney measuring 5.6 6.5 5.3 cm (Fig. 1), with radiographic features consistent with renal cell carcinoma, common bile duct (CBD) dilatation to 1.7 cm, and mild heterogeneity and prominence of the pancreatic head with no clearly defined mass and no vascular invasion. A subsequent magnetic resonance imaging of the abdomen with and without contrast and magnetic resonance cholangiopancreatography revealed an indeterminate area in the pancreatic head measuring 2.0 1.8 cm, CBD dilation to 1.4 cm with abrupt narrowing in the pancreatic head, and the previously identified centrally necrotic left lower pole renal mass. Endoscopic ultrasound (EUS) was then performed for further evaluation of the pancreatic mass. The EUS revealed a hypoechoic and anechoic mass in the pancreatic head measuring 3.2 2.7 cm with poorly defined borders, with CBD dilatation to 1.5 cm without vascular invasion (Fig. 1). Fine-needle aspiration (FNA) of the pancreatic mass
was performed via duodenal approach, with pathology revealing pancreatic adenocarcinoma. Preoperative CA 19-9 level was 342.9 units/mL. The patient underwent combined Whipple procedure and partial left nephrectomy. Surgical pathology confirmed primary pancreatic adenocarcinoma and primary renal cell carcinoma.
DISCUSSION Renal cell carcinoma metastasizing to the pancreas is well described and can result in isolated mass lesions in the head, body, or tail of the pancreas.2,6 These lesions can simulate primary pancreatic tumors, but their management may not be the same. Diagnosis of renal cell carcinoma is primarily made via classic imaging characteristics with management of primary lesions being almost exclusively surgical for pathologic confirmation and resection.7 The EUS with FNA of pancreatic mass lesions has been increasingly used for preoperative diagnosis.8 In this case, the use of EUS with FNA yielded histologic examination result that confirmed the presence of a primary pancreatic adenocarcinoma and not a metastatic lesion from the presumed renal mass. Other tumors that may metastasize to the pancreas include lung, breast, melanoma, and gastrointestinal tract (stomach, small bowel, colon, and rectum).1,3Y5 To date, there are 4 reports comprising 6 patients with synchronous diagnosis of histologically proven pancreatic adenocarcinoma and renal cell carcinoma, published in the English language.9Y12 Although 2 synchronous primary tumors are rare to find, it is important to approach solid masses of the pancreas as if they could be a primary pancreatic tumor in combination with a second primary tumor to enable appropriate diagnostic evaluation and proper therapeutic interventions.
FIGURE 1. A, Endoscopic ultrasound image of a hypoechoic mass in the head of the pancreas measuring 3.2 2.7 cm with anechoic areas and poorly defined endosonographic borders. B, Coronal image from the abdominal computed tomography scan with intravenous contrast of an enhancing mass in the lower pole of the left kidney measuring 5.6 6.5 5.3 cm. * 2014 Lippincott Williams & Wilkins
www.pancreasjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
663
Pancreas
Letters to the Editor
ACKNOWLEDGMENTS There were no sources of funding or financial disclosures for this manuscript. Study funding was provided exclusively by institutional funds. No outside funding sources were obtained. The authors declare no conflict of interest. Jodie A. Barkin, MD Atoosa Rabiee, MD Enrico O. Souto, MD Division of Gastroenterology Department of Medicine University of Miami Leonard M. Miller School of Medicine Miami, FL [email protected]
2. Wente MN, Kleeff J, Esposito I, et al. Renal cancer cell metastasis into the pancreas: a single-center experience and overview of the literature. Pancreas. 2005;30:218Y222.
&
Volume 43, Number 4, May 2014
guidelines/renal-mass.cfm. Accessed November 7, 2013.
3. Olson MT, Wakely PE Jr, Ali SZ. Metastases to the pancreas diagnosed by fine-needle aspiration. Acta Cytol. 2013;57:473Y480.
8. Puli SR, Bechtold ML, Buxbaum JL, et al. How good is endoscopic ultrasound-guided fine-needle aspiration in diagnosing the correct etiology for a solid pancreatic mass?: a meta-analysis and systematic review. Pancreas. 2013;42:20Y26.
4. Adsay NV, Andea A, Basturk O, et al. Secondary tumors of the pancreas: an analysis of a surgical and autopsy database and review of the literature. Virchows Arch. 2004;444:527Y535.
9. Bharthuar A, Pearce L, Litwin A, et al. Metastatic pancreatic adenocarcinoma and renal cell carcinoma treated with gemcitabine and sunitinib malate. A case report. JOP. 2009;10:523Y527.
5. Roland CF, van Heerden JA. Nonpancreatic tumors with metastasis to the pancreas. Surg Gynecol Obstet. 1989;168:345Y347.
10. Kawabe K, Ito T, Okano S. Simultaneous double cancers in the pancreas. Clin Gastroenterol Hepatol. 2011;9:A40.
REFERENCES
6. Kassabian A, Stein J, Jabbour N, et al. Renal cell carcinoma metastatic to the pancreas: a single-institution series and review of the literature. Urology. 2000;56:211Y215.
11. Alexakis N, Bosonnet L, Connor S, et al. Double resection for patients with pancreatic cancer and a second primary renal cell cancer. Dig Surg. 2003;20:428Y432.
1. Robbins EG 2nd, Franceschi D, Barkin JS. Solitary metastatic tumors to the pancreas: a case report and review of the literature. Am J Gastroenterol. 1996;91:2414Y2417.
7. American Urological Association. Guideline for Management of the Clinical Stage 1 Renal Mass 2009 [cited 2013 November 7, 2013]. Available at: http://www.auanet.org/education/
12. Mu¨ller SA, Pahernik S, Hinz U, et al. Renal tumors and second primary pancreatic tumors: a relationship with clinical impact? Patient Saf Surg. 2012;6:18.
664
www.pancreasjournal.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
